Prevalence, frequency, and disability of migraine headaches and tension headaches among the general population in the Eastern Region of Saudi Arabia

A tension-type headache (TTH) is a recurrent headache that is mild to moderate in intensity, unlike migraine (MH), which is accompanied by crippling effects of nausea, vomiting, photophobia, or phonophobia. TTH is more frequent than migraine, but it is less likely to cause severe pain and physical dysfunction. TTHs account for more lost workdays due to their prevalence. The study aimed to evaluate the prevalence, frequency, and disability of MHs and TTHs among the general population in the Eastern Region of Saudi Arabia. A cross-sectional study was employed using a validated questionnaire. The questionnaire implemented the HARDSHIP algorithm to diagnose MH and TTH and questions to correlate their prevalence to socio-demographic data, measurement of the level of disability, headache management, and treatment effectiveness using the chi-square test. The study reviewed 877 subjects (46.6% males vs. 53.4% females). 52.9% of the participants experienced headaches during the previous three months, and 35.6% experienced headaches recently. The most common type of headache was a probable MH (32.1%), followed by a TTH (26.9%), probable TTH (19.5%), and MH (15%). It was reported that some disability was attributed to 47% of MHs and 26% of TTHs. The most commonly used headache medication was paracetamol (53.5%). This study revealed that TTH and MH are common illnesses in Saudi Arabia's Eastern Region. TTH and MH are correlated with significant individual and social burdens, particularly for MH. Headache sufferers mostly manage their headaches using conventional over-the-counter methods.


INTRODUCTION
Headache is one of the most prevalent complaints of patients seen in internal medicine and adult neurology clinics [1]. Although it is among the top 10 complaints in outpatient medical care, we still do not fully grasp the epidemiology of headache problems. Most recurring headache cases are brought on by benign, primary, chronic headache diseases, including tension-type headache (TTH) and migraine (MH). Less commonly, other underlying illnesses such as infections, cerebral hemorrhages, and brain lesions might cause headaches [2].
Migraine is marked by symptoms of nausea, vomiting, phonophobia, and photophobia and last four to 72 hours. They are unilateral, have a pulsating quality, moderate to severe intensity, and are exacerbated by physical activity. Aura signs can occur before a migraine [3]. Emotional stress, poor or prolonged sleep, odors, skipping a meal, and menstruation are all potential triggers of migraine attacks [4]. Active MHs are estimated to affect 26.97% of people in Saudi Arabia, 14% of people in Europe, and 11% of the global population [5,6]. Migraine incidents increase after puberty, and women are more likely than men to suffer from them [7]. According to some research, the prevalence of MHs is rising due to unidentified causes [8].
Headaches and MHs are significant contributors to the burden of treatment in primary care services due to their high prevalence rates [7]. Headache disorders are the second leading cause of years lived with disability worldwide, according to the burden of disease research [9]. MH can be so debilitating that they necessitate repeated visits to outpatient clinics and emergency departments, resulting in substantial clinical and financial costs. In 2009, headaches were one of the top five reasons for emergency room admissions and one of the top 20 reasons for JOURNAL of MEDICINE and LIFE outpatient visits in the United States (US) [10]. Headaches, especially MHs, put a considerable financial and social strain on sufferers as well as society as a whole due to decreased quality of life, lost productivity, and the use of healthcare services [11]. In the US, the annual burden of MHs on employers is estimated to be around $13 billion, with annual treatment expenses above $1 billion [12]. Individuals suffering from MHs are more likely to experience underlying medical problems, chronic pain conditions, ischemic stroke, sleep disruption, depression, anxiety, and a rise in stress [13]. Despite the fact that MH is a serious disability, many individuals who suffer from it do not pursue medical treatment, and MHs are, therefore, significantly underreported and undertreated [14].
Tension-type headaches range widely from occasional short-term periods of discomfort to regular, long-term, or persistent ones in frequency, duration, or intensity [15]. TTH could coexist with MH often, but distinguishing between a TTH and milder types of MH without aura can be difficult [16]. A TTH is a recurrent headache that is mild to moderate in intensity and not accompanied by the crippling MH effects of nausea, vomit-ing, photophobia, or phonophobia [11]. In addition, a TTH is more frequent than MH, with a prevalence ranging from 30% to 70%, but it is less likely to cause severe pain and physical dysfunction. While MH sufferers are more likely to miss work, TTHs account for more missing workdays due to their prevalence [17]. A study in Denmark states that only 16% of people with TTH have contacted their general practitioner because of their TTH, compared to 56% of MH sufferers [18]. The cost of treating a TTH is twice as high as treating MHs, considering the higher incidence of TTHs [19].
To our knowledge, no study in the Eastern Region of Saudi Arabia focused on the disability caused by MHs and TTHs. To reduce the burden of headaches in the community and reinforce efforts to improve the patient's quality of life, it is critical to understand its distribution, related sociodemographic and clinical characteristics, and pathogenic processes. Identifying the underlying factors might result in enhanced preventative efforts and the early identification of vulnerable groups. We aimed to evaluate the prevalence, frequency, and disability of MHs and TTHs among the general population in the Eastern Region of Saudi Arabia.

MATERIAL AND METHODS
A cross-sectional questionnaire-based study was conducted using a previously validated questionnaire adapted and distributed electronically through social media platforms to all adult headache sufferers from the Eastern Province of Saudi Arabia. The questionnaire included several questions, including socio-demographic data, headache-type diagnostic algorithms, measurement of the level of disability, headache management strategies, and their effectiveness. The study was conducted between August 2021 and March 2022. Participants were recruited through an online survey from the eastern region. Participants who refused or were below 18 or non-Arabic speakers were excluded.
Regarding the implemented diagnostic algorithm, the HARDSHIP algorithm [20] was used to classify episodic headaches in hierarchical sequence: first definite MH, then definite TTH, then probable MH, and finally, probable TTH. Cases falling into none of these categories were "undetermined". During subsequent analysis, MH and probable MH were considered as one category in further discussion. In addition, TTH and probable TTH were considered as one category. Medication overuse headaches (MOH), which require direct clinical encounters with patients, were excluded.
According to the Saudi Arabia General Authority for Statistics, the latest statistics of the population of Eastern Province above 18 years of age are estimated at 2,356,197 [21]. Therefore, 385 participants recruited from Saudi Arabia's gener-al population were considered the minimum sample size required for this study, with a 95% confidence interval and a 5% margin of error [22]. The data were analyzed using the Statistical Packages for Social Sciences (SPSS) version 26 (Armonk, NY: IBM Corp). Categorical variables were presented using numbers and percentages. The relationship between the MH and TTH overall prevalence was correlated to sociodemographics and patients' control over the conditions using the chi-square test. A p-value cut-off point of 0.05 at 95% CI was used to determine the statistical significance.

RESULTS
This study contacted 877 subjects and excluded 43 individuals who had never experienced a headache, as shown in Figure 1. Furthermore, after analyzing the data through the HARDSHIP algorithms, we excluded the other unstudied types of headaches (possible MOH=28 subjects, undetermined headache=26 subjects), as illustrated in Figure 2. As seen in Table 1, the most common age group was 18-29 years (38.1%), nearly 60% were married, and a half (50.1%) were employed. Participants who earned less than 5,000 SAR per month constituted 42.4%, while others had monthly earnings of 10,001-15,000 SAR per month (21.3%) or 5,000-10,000 SAR per month (20.5%). Figure 1 shows the last time the participants experienced a headache. 52.9% of the participants experienced headaches during the previous three months, and 35.6% experienced headaches recently.
The prevalence of the type of headache is illustrated in Figure 2. The most common type of headache was a probable MH (32.1%), followed by a TTH (26.9%), probable TTH (19.5%), and MH (15%). In this study, MH and probable MH were considered as one category in further discussion. In addition, TTH and probable TTH were also considered as one category.
We then asked diagnostic questions to participants who experienced headaches (n=780). Following the results, we observed that around two-thirds (66.3%) of the participants experienced a headache for less than seven days during the previous month, which lasted between 30 minutes and four hours (53.6%). Furthermore, moderate headache was experienced by 58.5% of respondents, with pressure being the most common nature of headaches (50.5%). 66.7% reported that the headache was localized in one area, while 34.9% reported that the headache increased with exercise. Incidentally, the most common symptom reported was phonophobia (22.6%), followed by photophobia (13.6%), while 35.3% experienced both symptoms. In addition, 42.7% took medication for less than five days, and 48.6% did not take any medication at all ( Table 2).
The disability questions among participants who experienced headaches are given in Table 3. It revealed that 38.1% of respondents indicated that the severity of headaches did not affect their daily lives. 56.3% of TTH patients could do everything normally; on the other hand, 36.4% of MH sufferers could only do half of what they needed to do. The significance of respondents who could do things normally at work or school despite their headache (p<0.001) was higher with TTH compared to MH, 66.7% of whom expressed that the headache did not affect their presence at work or school. With regard to the sub-type headache, 80.9% of TTH said it did not affect their presence at job or school, while 52.7% of those with MH said it did not affect their job or school. It is notable that those with MH missed  Table 4, the most commonly used medication for headaches was paracetamol (53.5%). On the other hand, 38.3% expressed that the medication significantly decreased the headache duration, 34.6% of whom were MH sufferers who experienced a minimum reduction in duration due to the effects of medications in comparison to those with TTHs (23.8%). Accord-ingly, 30.0% of the respondents reported that their headaches could not be controlled, and 36.1% of those with MHs said they could not control them in comparison to 23.8% with TTHs. In addition, the number of respondents who reported that they can control headaches a little (p<0.001) was significantly higher in the MH group. The prevalence of respondents who reported that they felt anxious, even during headache-free days, was 33.6%, with 43.8% of those suffering MH feeling anxious even during headache-free days, compared to 23.3% with TTHs. Moreover, the number of people who felt anxious during headache-free days (p<0.001) was significantly higher in the MH group, while the prevalence of respondents who could not do anything in fear of a headache was 20.8%, 30.0% of whom had MHs compared to 11.4% with TTHs. In addition, there was a significant relationship between those who indicated that they could not do anything during headache-free days in fear of a headache (p<0.001) being less in the TTH group.
When measuring the relationship between the type of headache and the socio-demographic characteristics of the participants, it was found that being married (p<0.001), being employed (p<0.001), and having a headache for the previous three months (p<0.001) was more significant for having TTHs, while the age group of 18-29 years (p<0.001), females (p<0.001), and  Table 5. Relationship between the type of headache and the socio-demographic characteristics of the participants (n=780). § -P-value has been calculated using the chi-square test; ** -Significant at p<0.05 level. those with less than 5,000 monthly earnings (p<0.001) were significant for MHs (Table 5).

DISCUSSION
The present study investigated the prevalence and disability of MH and TTH among the general population in the Eastern Region of Saudi Arabia. The prevalence of MHs in this study was 15%. This is consistent with the paper by AlQarni et al. [23]. Based on their accounts, the prevalence of MHs among adults living in the Aseer region of Saudi Arabia was 12.3%. For university students, the prevalence of MHs was in agreement with our results, with studies indicating that the prevalence of MHs among medical students was 15.4% and 17.9%, respectively [24,25]. Other publications that have reported MH prevalence were within our range, including a study published in Nigeria [26], Brazil [27], Italy [28], and Turkey [29]. On the other hand, a study conducted in Taif, Saudi Arabia [30] detected a higher MH prevalence among female Saudi students at Taif University, at 32.5%, which was in accordance with the paper of Kandil et al. [31]. We further noted that the prevalence of probable MHs was higher in our population, accounting for 32.1%. This prevalence rate is higher than in other studies. For example, in Pakistan [24], the prevalence of probable MHs was 15.4%, while in Brazil [27], the prevalence was 8%, whereas, in Egypt, it was 12.5%. We have recorded that the prevalence of probable MH was the highest in our study, and no other study has recorded the same result.
The prevalence of TTH in this study (26.9%) lies within the range of studies, as reported in Taif, Saudi Arabia [30], and in Southeast Nigeria [26]. The highest prevalence rate of TTH was reported by Prencipe et al. [28], with a prevalence of 44.5%, which was surveyed among three villages in central Italy. Some papers have reported a lower prevalence rate. For instance, in a study conducted by Falavigna et al. [27], the prevalence of TTH was 12.8%, while in Kandil et al. [31], the prevalence of TTH was 13.6%. In addition, Ertas and colleagues [29] reported the lowest 1-year prevalence rate of 5.1%. The probable TTH prevalence among our population was 19.5%, which was in agreement with the study conducted among university students [24,27]. However, in Turkey [29], the prevalence of probable TTH was lower, at 9.5%.
A younger age group (18-29 years), female respondents, and a low monthly income among participants demonstrated a significantly higher probability of having an MH. These findings are almost in agreement with the paper of Constantinides et al. [32], who found that MH patients had a significantly lower age at headache onset and frequency, higher mean visual analogue scale (VAS), and greater maximum duration of headache episodes compared to TTH patients. Similarly, we observed that the prevalence of TTH was significantly higher among working JOURNAL of MEDICINE and LIFE participants and those who had had a headache during the previous three months. In Egypt [25], researchers have observed a relationship between the severity of TTH and some of the demographic characteristics of the respondents. The study showed that the severity of TTH was associated with age, specifically after the age of 40, while prolonged TTH was found to be five-fold in unmarried individuals and two-fold in a large number of children.
In our further review, compared to TTH subjects, MH subjects described that 15.5% could not do their work at all, which represents a tremendous disability, while 47.6% of the MH sufferers stated that they could only finish less than half of their daily activities at work or school. This is consistent with the paper of Edmeads et al. [33], who reported that some disability was attributed to 47% of reported MHs and 26% of reported TTHs. Similarly, 15.3% of MH subjects missed the whole day either at school or at work. However, in America, they revealed that around 31% of all MH missed at least one day of work or school due to headaches [34]. Meanwhile, TTH subjects said that headaches affected them at work for less than seven days during the previous three months. In a paper conducted by Radtke et al. [35], MH was more severely impacted by headaches than non-migraine headache sufferers, as demonstrated by a higher number of headache days.
In the present study, compared to MH subjects, 56.3% of TTH subjects could do everything normally in their daily lives, and 80.9% expressed that the TTH did not affect them at all while they were at work or school. In addition, 86.3% of the TTH subjects stated that headaches affected them at work for a maximum of seven days during the previous three months, while 37% of the TTH subjects stated that their colleagues and supervisors understand them just a little. Incidentally, compared to TTH, 47.6% of MH sufferers stated that they were able to finish less than half of their daily activities at work or at school. In Egypt, however [25], they revealed that headaches increased with daily activities, with similar findings in Southern Brazil [27], where the pain worsened with the students' daily activities.
Paracetamol was the common choice of analgesic for the treatment of headaches, with 38.3% of the subjects stating that the medication reduced the duration a lot, and 42.7% indicated that they usually took medication for less than five days. Several studies have also indicated paracetamol is the chief medication for headaches [25,[29][30][31]. Oraby and associates [25] further stated that the self-prescription of medications for MHs was practiced by 58.4%, while 25.7% used doctor's prescriptions. In previous publications, paracetamol was regarded as the most popular due to its low price, safety, and less gastrointestinal tract (GIT) adverse effects. In addition, it can be purchased over the counter at any convenience or pharmacy store [36,37].

CONCLUSION
This study revealed that TTH and MH are common illnesses in Saudi Arabia's Eastern Region, accounting for 26.9% and 15%, respectively, and that they are correlated with significant individual and social burdens, particularly in MH sufferers. MH is a huge burden on the healthcare sector, as it causes more severe symptoms and more frequent attacks, which impose more disability on the patient. In addition, headache sufferers tend to manage their headaches using over-the-counter conventional methods, with less than 9% fully controlling their headaches.
To reduce the burden on the healthcare sector imposed by TTHs and MHs, we recommend raising awareness among phy-sicians and patients to identify each type of headache and treat it accurately through correct and timely counseling and medication.
Further study is needed in the future to minimize errors and direct patients toward ways to lower the incidence of disability as much as possible. Per limitations, this study selected the population as general Eastern Province citizens, which could be specified in further studies to classify the Eastern Province population according to the city of residence.